Individual differences pack 2

The biological/medical approach dominates the diagnosis and treatment of Psychopathology.  Medically trained psychiatrists and doctors are responsible for treating patients with mental health problems and use three main types of treatments: psychosurgery (not in the exam), ECT and drugs.  Each of these treatments are based on the assumption that the cause of psychological disorder lies in underlying physiological processes in the body.

Psychosurgery

As a last result when drugs and ECT have apparently failed psychosurgery is an option. This basically involves either cutting out brain nerve fibres or burning parts of the nerves that are thought to be involved in the disorder

During ECT, a brief electrical stimulus is given to the brain via electrodes placed on the temples. This electrical charge causes an epileptic-like seizure.

Before treatment, the patient is anaesthetised and given an injection of muscle relaxant which depresses the breathing, and oxygen is given until the patient is able to breathe naturally again. Most patients get a total of six to twelve ECTs at a rate of one a day, three times a week. 

ECT is usually given to people with severe depression which has not responded to other forms of treatment such as anti-depressants. However, it is sometimes used for those with a diagnosis of bi-polar affective disorder (manic depression) or schizophrenia.  It is usually only given after the risks have been explained and with the person’s consent, or in the extreme case when the person’s life is at risk This is not clear, but there are numerous theories including the following:  

• Neurotransmitter theory:  ECT works like anti-depressant medication, changing the way brain receptors receive important mood-related chemicals.
•    Neuroendocrine theory:  The seizure causes the hypothalamus to release chemicals that cause changes throughout the body. The seizure may release a neuropeptide that regulates mood.
• Brain damage theory:  Shock damages the brain, causing memory loss and disorientation that creates an illusion that problems are gone, and euphoria, which is a frequently observed result of brain injury. Both are temporary.

Psychological theory:  Depressed people often feel guilty, and ECT satisfies their need for punishment. Alternatively, the dramatic nature of ECT and the nursing care afterwards makes patients feel they are being taken seriously; i.e. the placebo effect

Does it work? ECT has been found to be effective in the treatment of depression.  Petrides et al (2001) reported that between 65% and 85% of depressed patients have a favourable response to ECT.  Additionally, Pagnin (2004) carried out a meta-analysis which compared the effectiveness of ECT against various types of anti-depressants and simulated (or sham) ECT.  ECT was more effective in the treatment of depression than anti-depressant drugs or simulated (sham) ECT.  

Research has shown that it is effective - see Petrides (2001) and Pagnin (2004) above.  Additionally, Comer (2002) states that 60-70% ECT patients improve after treatment. 

 Ethical implications - Can we also justify using a treatment such as ECT when we are unsure how it actually works??!!! As ECT is mainly used for severe depression it is possible that these individuals may not grasp the nature and consequences of ECT and so cannot give fully informed consent.  Furthermore, a meta-analysis of 17 papers covering 134 testimonies of ECT patients found that almost half of those who had received ECT felt that they were not given enough information about the procedure, and approximately half felt that they had been coerced into having the treatment (Rose et al, 2005).

 Sham ECT- although studies such as the one by Pagnin (2004) demonstrated that ECT was more effective than “sham” ECT some patients who received the sham treatment still recovered suggesting that such treatment may have a “placebo effect”.  

Side effects (both physical and psychological) - ECT is associated with numerous side effects including memory loss cardiovascular changes and headaches (Datto, 2000). The DOH report (1999) found that among those receiving ECT within the last two years, 30% reported that it has resulted in permanent fear and anxiety. 

Approximately 25% of all drugs prescribed by the NHS are for mental health problems.  Psychiatric drugs modify the working of the brain and affect mood and behaviour.  They work by entering the bloodstream in order to reach the brain, and act there to affect the transmission of chemicals in the nervous system.  These chemicals are called neurotransmitters and have a variety of effects on behaviour.  The main neurotransmitters are dopamine, serotonin, acetylcholine, noradrenaline and GABA.  Drugs simply increase or decrease the availability of these neurotransmitters and hence modify their effects on behaviour.  A drug that blocks the effect of a neurotransmitter is called an antagonist, one that mimics or increases the effect is called an agonist. 

In the 1950s two important discoveries changed the outlook for millions of people suffering with mental illness.  Antipsychotics were able to control the symptoms of schizophrenia, making it possible to move thousands of people from psychiatric hospitals back to the community.  Another family of drugs discovered around the same time, the tricyclics, helped vast numbers of people suffering from depression lead normal lives, until the discovery of the SSRIs (selective serotonin re-uptake inhibitors) in the 1980s. 

Antipsychotic drugs

 Conventional antipsychotics (eg chlorpromazine) are used to combat the positive symptoms of schizophrenia. Tricyclics to treat depression.

Schizophrenia is a severe psychological disorder, the key symptoms for which are hallucinations and delusions (known as positive symptoms) and emotional blunting and lack of motivation (known as negative symptoms).  Patients also suffer from a loss of insight and contact with reality.

Antipsychotics, such as chlorpromazine block the action of the neurotransmitter dopamine in the brain by binding to, but not stimulating dopamine receptors.

 Newer antipsychotic drugs (such as clozapine) act by only temporarily occupying dopamine receptors and then rapidly dissociating to allow normal dopamine transmission.  They also seem to act on a wide range of neurotransmitters in the brain, including serotonin and dopamine.  Such differences may explain why these so-called atypical antipsychotics have lower levels of side effects (such as tardive dyskinesia – involuntary movements of the mouth and tongue) compared to conventional antipsychotics.

Antidepressant drugs

 Depression is thought to be caused by insufficient amounts of neurotransmitters such as serotonin being produced in the nerve endings.  In normal brains, neuro-transmitters are constantly being released from the nerve endings, stimulating the neighbouring neurons.  To terminate their action, neurotransmitters are re-absorbed into the nerve endings or broken down by enzymes.  Antidepressants work either by reducing the rate of re-absorption or by blocking the enzyme which breaks down the neurotransmitters.  Both of these mechanisms increase the amount of neuro-transmitter available to excite neighbouring cells.

The most commonly prescribed antidepressant drugs are the SSRIs.  These work by blocking the transporter mechanism that re-absorbs serotonin into the presynaptic cell after it has fired.  As a result, more serotonin is left in the synapse, prolonging its activity, and making transmission of the next impulse easier.

Other drug groups

Anti-anxiety drugs:  also known as minor tranquillisers, they include drugs such as Librium and Vallium, both examples of benzodiazepines.  These drugs are used in the treatment of general anxiety, stress and for sleep disorders.

Lithium:  this is an unusual drug used principally for treating bipolar depression. 

Could also include Betablockers as another anti-anxiety drug

Effectiveness

Research evidence indicates that chemotherapies do work, eg WHO (2001) (World Health Organisation) reported that relapse rates after one year were highest when schizophrenia suffers were treated with placebos (55%), 25% when treated with chlorpromazine alone and 2%-23% when chlorpromazine was combined with family intervention.  This suggests that drugs play an important role in treatment, but are not the only factor in managing psychiatric disorder.

However, it appears that drugs don’t work for between 40% and 50% of patients with schizophrenia; for depression 30% of patients respond to placebo treatment!

 Ease of use - Tablets take very little effort, both for doctors to prescribe and for patients to take.

Symptoms or cause? - Drugs only alleviate the symptoms of disorders.  As soon as patients stop taking the drugs, the symptoms return.

Side effects - All drugs have side effects.  SSRIs may cause anxiety, sexual dysfunction, insomnia, nausea and suicidal thoughts.  Furthermore, patients may develop a psychological or physical dependence with prolonged use.

Psychological therapies are based on psychological approaches to psychopathology and focus more on the psychological dimensions of behavior (how people think and feel) than does the biological approach.  Having looked at 3 psychological approaches to psychopathology, we’ll look at an example of a therapy associated with each of these approaches.

Freud’s approach to psychological disorders makes several assumptions:

·         Adult neuroses, such as anxiety and depression, are rooted in early childhood experiences

·         The adult is protected from the conflicts that lie at the root of these problems by ego defence mechanisms

·         All such problems are situated in the unconscious mind, and so are not readily accessible to the individual concerned

The aim of psychoanalytic therapy is to uncover the repressed material and help the client come to an understanding of the origins of their problems.  There are traditionally several techniques available to the therapist, the three we will consider are:  free association, deam analysis and projective tests.

In this therapy the client is encouraged to say anything that comes into their mind, whether it seems important or not.  Freud believed that the value of free association lies in the fact that these associations are determined by unconscious factors, which analysis tried to uncover.  The client is encouraged not to censor what s/he says, with the hope that such freedom will lead to a lowering of ego defence mechanisms so that repressed material can be accessed.  The role of the therapist is to intervene occasionally, to encourage reflection and to identify key themes and ideas that can be analysed further. 

This technique may be used alone or alongside dream analysis.

Freud referred to dreams as the ‘royal road to the unconscious’.  He felt that in the dreaming state, all barriers to unconscious material were lowered, and the symbolic imagery of dreams was a reflection of this unconscious material. 

 Freud suggested that dreams were essentially wish fulfillment, but that the wishes (often sexual or aggressive urges coming from the id) may be too threatening to be consciously acknowledged.  They were therefore distorted and reflected in the imagery of the dream.  Hence, according to Freud, all dreams have an obvious content, which he called the manifest content, but beneath this lies the actual meaning of the dream that can only be accessed through interpretation.  This was known as the latent content.  Dream work involves changing manifest content into latent content.  The role of the therapist is to use their understanding to interpret the symbolism of the dream.

Although not part of Freud’s original therapeutic techniques, projective tests are used in a variety of psychodynamic approaches.  In these tests the client is required to project or impose their own thoughts and associations onto some fairly ambiguous material.  The most famous is the Rorschach ink blot test, in which the client is presented with a series of ink blot shapes.  They are asked what the shape means to them, and by repeating this with a sequence of different blots particular themes and anxieties may emerge.

Effectiveness 

Bergin (1971) analysed the data from 10,000 patients hand found that 80% benefited from psychoanalysis compared to 65% from eclectic therapies (ie treatment based on a number of different approaches). In fact, Freud spoke in terms of reducing unhappiness, rather than curing it! Psychodynamic therapies depend upon the client developing insights into their condition.  This means it is less suitable for people who are unwilling or unable to analyse their lives in this way.  It also makes it unsuitable for psychoses such as schizophrenia, where lack of insight is a major symptom. Not good for psychoses like schizphophrenia. Also time consuming so some people might not like them.

 Length of treatment 

Tschuschke et al (2007) carried out one of the largest studies investigating long-term psychodynamic treatment.  More than 450 patients were included in the study, which showed that the longer psychotherapeutic treatments took, the better the outcomes were.

Ethical issues Clients have to confront material which may be distressing during the course of analysis.  Working through issues such as childhood sexual abuse might be particularly traumatic not only for the client, but for those around him/her.

 Theoretical weaknesses

Psychoanalysis is based on Freud’s theory of personality; if that is flawed then the explanations of mental illness arising from this theory must be flawed, and the therapy itself must be flawed.

False memories

Critics of psychoanalysis claim that some therapists are not just bringing repressed memories to light, but are (unconsciously) planting ‘false memories’.

The behavioural approach assumes that disordered behavior is learned through classical and operant conditioning.  Therefore, the approach to therapy is to try and alter behaviour using the principles of conditioning.  The three main processes in the behavioural approach:  classical conditioning, operant conditioning and social learning are related to particular therapies.  Behaviour therapy refers to techniques based on classical conditioning, while behaviour modification refers to therapies based on operant conditioning and social learning.

 Systematic desensitisation is the most popular form of behaviour therapy, first developed by Wolpe (1958).  It is a form of counter conditioning, whereby the therapist attempts to replace the fear response with a harmless response.  In the case of treatment for a phobia this would involve the following steps:

• Creating a hierarchy of fear – ie a list of situations involving the object of fear going from the least to the most feared.
• The therapist trains the client in deep relaxation techniques.  A state of relaxation is incompatible with a state of anxiety.
• The therapist asks the client to visualize the least feared situation, whilst carrying out deep relaxation techniques.
• Once the client feels comfortable at that level, they are asked to imagine the next situation in the hierarchy, carry out the same procedure.
• Over a series of sessions the client will cope with every level of the hierarchy, although they can stop at any time and restart at a lower level.  

An alternative to visualizing fearful situations is to use real examples, pictures or models.

Other behavioural therapies include flooding and aversion therapy.

Other behaviour modification techniques include token economy programmes and the use of social learning techniques.

Appropriateness

Behavioural therapies in general are quick and require less effort on the patient’s part than other psychotherapies which need the patients to take an active role.  They may sometimes be the only treatments possible, particularly for individuals with learning difficulties. However, they offer a reductionist approach to complex behaviours and treat people as stimulus-response machines.

 Effectiveness 

 Research has found that systematic desensitisation is successful for a range of anxiety disorders.  For example, about 75% of patients with phobias respond to systematic desensitisation  (McGrath et al, 1990).  Capafons et al (1998) reported that when used with aerophobics, those who had undergone SD reported lower levels of fear (compared to a control group) and lower physiological signs of fear during a flight simulation.

 The problem of symptom substitution

SD may appear to resolve a problem, but it simply eliminates or suppresses symptoms, and the underlying problem may lead to other, different, symptoms appearing.

Reduced effectiveness for some phobias

Ohman et al (1975) suggest that SD may not be as effective in treating anxieties that have an underlying evolutionary survival component, eg fear of heights or the dark, rather than phobias acquired as a result of personal experience.

 A deterministic approach

The behavioural approach is heavily deterministic, viewing human behaviour as a product of stimuli, rewards and punishments.  There is apparently no role for conscious choice.

Reductionist - Doesn't acknowledge the complexity of psychological disorders, focusing only on behaviour; the underlying problem may remain.

The cognitive approach links psychological disorders to irrational and dysfunctional thoughts.  So, the aim of cognitive therapy (or more usually cognitive behavioural therapy) is to challenge these irrational and dysfunctional thought processes.  An example of the cognitive approach is Ellis’s rational emotive therapy. 

 Rational emotive therapy

 This therapy was developed by Ellis (1957).  It was based on the idea that many problems are the result of irrational thinking.  People develop self-defeating habits because of faulty beliefs about themselves and the world around them.  RET (or more recently REBT – rational emotive behavioural therapy) helps the client understand this irrationality and its consequences.  It then helps them to substitute more effective problem-solving methods.  

REBT focuses on the self-defeating beliefs that accompany the events which activate anxiety.  During therapy, the patient is encouraged to dispute these beliefs:

·         Logical disputing – self-defeating beliefs do not follow logically from the information available.  (In other words, the client is encouraged to consider “Does thinking this way make sense?”.)

·         Empirical disputing – self-defeating beliefs may not be consistent with reality (eg “Where is the proof that this belief is accurate?”)

·         Pragmatic disputing – emphasizes the lack of usefulness of self-defeating beliefs (eg “How is this belief likely to help me?”)

Effective disputing changes self-defeating beliefs into more rational beliefs.  The individual can move from catastrophising to more rational interpretations of events.  This, in turn, helps them to feel better and eventually become more self-accepting.

REBT (as an example of a therapy using the cognitive behavioural approach)

Effectiveness

REBT has generally done well in outcome studies.  For example, in a meta analysis, Engels et al (1993) concluded that REBT is an effective treatment for a number of different types of disorder, including OCD and social phobia.

 Appropriateness - A particular strength of REBT is that it is not only useful for clinical populations (ie people suffering from mental disorders or phobias), but is also useful in non-clinical situations, eg for treating lack of assertiveness or examination anxiety.

Irrational environments

REBT does not address the nature of irrational environments in which clients live.  For example, living with a bullying partner, or having an over-critical boss may continue to produce and reinforce irrational thoughts and maladaptive behaviour.  The way in which negative thoughts sometimes reflect an accurate view of the world is known as depressive realism.

 Not suitable for all

Like all psychotherapies, REBT does not always work.  In this case some people may simply not co-operate in restructuring the way they think.

 Reductionism

This treatment fails to take account of genetic or physiological factors, which may influence the way an individual experiences a particular disorder.

Comparing the effectiveness of therapies is difficult since one type of therapy may be more effective for one disorder than another, eg systematic desensitization works well with phobias, schizophrenia responds best to antipsychotic drugs, and cognitive therapies can be effective in treating depression and anxiety states.  Furthermore, any study making comparisons faces practical difficulties:

• Large numbers of participants are needed, all of whom have the same disorder, equally as serious, for comparison across different therapy groups.
• There needs to be careful assessment of patients before and after treatment, with agreement as to how long intervention should last.
• When drug therapy is one comparison, a placebo must also be used with a control group.

Elkin et al (1989) 240 with depression, from a number of treatment centres, were treated with either CBT, psychotherapy or antidepressant drugs.  There was also a placebo control group.  Treatment lasted for 16 weeks. The findings were:

• There was a 35-40% placebo effect
• All therapies were more effective than placebo, and had similar levels of effectiveness
• Drugs tended to be the most effective therapy for severe depression
• The individual therapist was a significant factor in the effectiveness of psychotherapy
• Across all treatment groups, 30-40% of patients did not respond to therapy.

Davidson et al (2004)

 295 p's with generalized social anxiety were treated with CBT, the SSRI antidepressant fluoxetine, or with combined CBT + fluoxetine.The findings were:

• The overall placebo effect was 19%
• All therapies were more effective than placebo, and after 14 weeks there were no differences between the therapy groups.
• 40-50% of patients did not respond to therapy

 The conclusions were that drugs and CBT are equally effective, but many patients did not respond to either treatment.

Individual differences - Factors such as age, gender, socioeconomic status, and even severity of disorder are often impossible to control.

 Length of study - Ideally observation should continue for at least a year to check that any improvement continues.

Control group -There should be a non-treated group to control for the specific effects of treatment.  In drug trials, this involves a placebo group; for psychological therapies it’s more difficult.  Often an ‘interaction’ condition, where the patient talks to the therapist, but is given no specific techniques, controls for the effects of being given attention by the therapist.

 Measuring improvement - This should be consistent across the groups.  Both patients and practitioners should assess improvement, preferably with the practitioners not knowing which group the patients were in, to prevent bias and investigator effects.

 Ethical issues - If a non-treatment control group is used, they miss the benefits of treatment, though no doubt will be treated in the future, once effectiveness is established.